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UNDERGROUND STORAGE TANK SYSTEM <br />DESIGNATED UST OPERATOR MONTHLY INSPECTION <br />Facility Name: Lathrop Gas and Food -Chevron Inspection Date: D, <br />Facility Address: 140 E. Lathrop Road City: Lathrop <br />Name of Designated UST Operator Conducting Inspection: Alex Jabbari <br />International Code Council Certification No,: 5243897 -UC Expi <br />Signature: P4,el Phon <br />Item MONITORING PANEL / ALARM HIS'T'ORY <br />I• Is the monitoring s stemveered on and in pro operating mode? <br />2. Is the monitoriny, system not currently showin2 anV leak alarms? <br />3. Is the Alarm History Report/log for the previous month available, and has it been <br />Designated UST Operator? (Attach a copy of the alarm histoEy re oL o to this <br />4. Has each alarm for tlye)revious month been responded to appropriately? <br />UST SYSTEM INSPECTION <br />5. Are tank -top containment sumps free of water, debris, and hazardous substance? <br />"NA" strip to Item 6. Sumps where mi alarm has occurred in the past month must be inspected tf a Q <br />to and r ttdri>essed the cause o the alarm. Documentation vera tit ro lore service shoo, <br />No msum s alarm Yes No No msum <br />Sump Location. Sump Location: <br />Sump Location: Sump Location: <br />6. Ares ill buckets containment structures free of water, debris, and hazardous sut <br />Yes No N/A <br />Tank l ID — Regular I Lj Tank 3 ID — Diesel <br />Tank 2 1D — Premium Z I LJ I Q Tank 4 ID — <br />7. Are under -dispenser containment areas free of water, debris, and hazardous substa <br />YesI No NIA <br />Dispenser — l /2 Dispenser -9/10 <br />Dispenser - 314 U Dis nser — 11/12 <br />Dispenser — 516 Dis eraser —13114 <br />Dispenser — 7/8 <br />Dispenser — 15116 <br />8. Leak detection is properly located within under -dispenser containment. <br />Yes No T N/A <br />mber 4, 2313 <br />T <br />n Date: 13/6/2014 <br />(925) 38 -1262 <br />N/A = Not Applitable <br />jYesj No i NIA <br />by the <br />the answer o !tent 4 was "Yes, "or <br />,rvice techn ion has not responded <br />bed to this <br />YesNo <br />Dispenser — 1/2 <br />Dispenser — 9110 <br />Dis nser — 314 Dispenser — 11/12 <br />Dispenser — 5/6 Dis enser —13/14 <br />Dispenser — 7/8 Dispenser — 15/16 <br />PAPERWORK INSPECTION Y No <br />9. Monitoring System Certification was completed within the past 12 months? <br />10. Secondary containment tests completed within the required time frame? <br />11. Spill bucket (containment structure) testing completed within the past 12 months? <br />12. Tank tightness testing completed within the required time frame? <br />13. Line tightness testing completed within the required time frame? <br />15. Other required testis maintenanec was completed within required time frame? (List testi inainte, <br />Describe Test/Maintenance: ST27 & ST30 I El <br />Describe Test/Maintenance: <br />I Li Li <br />FACILITY EMPLOYEE TRAINING <br />Ffl]6-�Have all facilit em to received the re uired on-the-'ob trainin within the t <br />Have all facilityem to ees hired within the past 30 da s received the required on -the -j b training <br />Note: Explain any "No" answers in the "Comments" section on the following page. Those issu's require <br />the UST owner/operator. <br />Yes I No I NIA <br />Yes I No I N/A <br />Yes i No I NIA <br />Tate Done <br />e <br />12/31/2012 { f r <br />1/30/2012 <br />12/3112012 <br />